Basic Information
| Provider Information | |||||||||
| NPI: | 1295980274 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEFFLER | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SKABELUND | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1715 MCCULLOUGH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782124046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102255323 | ||||||||
| FaxNumber: | 2102257505 | ||||||||
| Practice Location | |||||||||
| Address1: | 1715 MCCULLOUGH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782124046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102255323 | ||||||||
| FaxNumber: | 2102257505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2008 | ||||||||
| LastUpdateDate: | 11/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 57.015117 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | P4249 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 57.015117 | 01 | OH | OHIO TRAINING CERTIFICATE | OTHER | 3371395-01 | 01 | TX | WELLMED MEDICAID | OTHER | 360019YLPS | 01 | TX | WELLMED MEDICARE | OTHER |